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					                                                Draft - North Bristol NHS Trust Healthcare Associated Infection Improvement Review
                                                                                     Action Plan
VISION - to achieve the required reduction in MRSA bacteraemia and sustain high standards of infection
* Deliver 100% compliance with Saving Lives Care Bundles
* No bacteraemias due to contaminants
* Clean commodes in all clinical areas
  Local Sub                 Current State                   Action             Executive   Operational Lead      Date of      Current Risk       Measure of          Evidence         Review Date
  Objective                                                                      Lead       and involved        Completion                        Success
                                                                                             individuals

1 - To        Incomplete RCA action         *     Review current RCA           DoN         DDoN               15.2.10                         New Process in    Minutes of COIC       28.2.10
provide       plan completion and                 process and                              Surveillance                                       place             identifying process
assurance     follow through                      responsibilities and include             Scientist                                                            sign off
that RCA                                          reporting routes and RCA
actions plans                                     sign off by Directorate
are                                               Management team
implemented                                 *     Review RCA training and      GMs/CDs/    Lead ICN and       May 31st       Release for      Numbers trained   Training Records
and reviewed                                      roll out to Ward Sisters       HoNs      CRM                               training                           on MLE
                                                  and AGMs                                                                                                      COIC minutes
                                            *     Detailed review of all RCAs DoN/CED      GMs/CDs/HoNs
                                                                                           Speciality Lead
                                            *     Action plan to be            CEO/MD/     Lead ICT and       3.4.10
                                                  developed within 48 hours    DoN         Risk Manager
                                                  of CEO review with a time
                                                  line of implementation for
                                                  actions


                                            *     Directorate representatives DoN DIPC     Directorate Lead                  Lack of                            COIC sign off
                                                  to report achievements                                                     compliance                         completed action
                                                  deliverables and risks at                                                  with
                                                  DIPC and COIC meetings                                                     implementation
                                                                                                                             of actions and
                                                                                                                             reporting to
                                                                                                                             COIC

                                            *     Completed action plans to    DoN/DIPC    DDoN               30.3.2010                                         COIC minutes
                                                  be signed off at COIC
                                                  within one month
                                            *     Identify Trust wide themes               ICT Lead Nurse
                                                  and required action




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State               Action                  Executive   Operational Lead      Date of      Current Risk       Measure of          Evidence   Review Date
  Objective                                                                       Lead       and involved        Completion                        Success
                                                                                              individuals

2 - Ensure          Limited competency      *   Identify lead for each area DoN             DDoN               8.2.2010                                                          30.4.2010
clinical staff      assessment                  of clinical practice
competence                                  *   Develop competency           DoN            DDON and Leads                    Training plans
in four key                                     assessment tools for                                                          and
aspects of                                      medical and nursing staff                                                     competency
clinical                                        for identifying training                                                      assessment not
practice                                        plans and methodology for                                                     achieved to
                                                roll out of assessment, set                                                   trajectory
                                                target/trajectories for each
                                                directorate


                                                  blood cultures                DoN         HoN Clinical     30.3.2010                         Records of staff   COIC reports
                                                                                            Support/PD Nurse                                   competence
                                                                                                                                               Compliance         TB Dashboard
                                                                                                                                               numbers achieved   report
                                                                                                                                               to trajectory
                                                  cannula insertion and         DoN         PD nurse           30.3.2010
                                                  ongoing care
                                                  Urinary catheter              DoN         PD nurse           30.3.2010
                                                  insertion and ongoing
                                                  care
                                                  Aseptic technique             DoN         DoN/HON Renal
                                            *   QA training plan                DoN         DMT                22.2.2010                       Approved robust
                                                                                                                                               education
                                                                                                                                               programme
                                            *   Identify directorate leads to                                                 Lack of          Assessment
                                                monitor and manage                                                            leadership in    Records
                                                assessment and                                                                directorates
                                                compliance




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State                 Action                Executive    Operational Lead       Date of      Current Risk      Measure of              Evidence         Review Date
  Objective                                                                       Lead        and involved         Completion                       Success
                                                                                               individuals

3 - Improve         Lack of audit and required *   Reset audit plan for each   DoN           DMT                 30.3.2010                      Audit Plan            Compliance
compliance          action to improve              directorate                                                                                                        minutes of
with Saving         standards                                                                IM&T                                                                     Directorate
Lives audits                                                                                                                                                          meetings
                                               *   Set and agree targets for   DoN           DDoN and IM&T       1.3.2010       Unable to       Clear Directorate   Reports from
                                                   individual wards and                                                         agree targets   structure/processes Directorates to
                                                   departments                                                                                                      COIC
                                               *   Restate responsibility for  DoN/DIPC      DDoN                1.3.2010                                             Reports / minutes     Monthly at
                                                   directorate lead and ward /                                                                                        to COIC               COIC
                                                   department manager for
                                                   compliance
                                               *   Develop a dashboard for     DoN           Head of Nursing /   30.3.2010
                                                   each ward or department                   Ward Manager
                                                   to include
                                                     Hand hygiene                                                28.2.2010
                                                     Peripheral venous         DoN           HoN                 28.2.2010                      Directorate reports   Mins of Directorate
                                                     cannula                                                                                    show compliance       meetings

                                                     Urinary catheter          DoN / DIPC    HoN                 28.2.2010                                            DIPC and COIC
                                                     insertion and ongoing                                                                                            Minutes
                                                     care
                                                     Equipment cleaning                      HoN
                                               *   Reports to be a standing    Director of   CD/GM               1.3.2010
                                                   item on all DMT monthly     Operations
                                                   meetings
                                                   Directorate monthly reports DoN / DIPC    Directorate Lead    30.3.2010                      Accurate reports      Mins of DIPC and
                                                   presented and reviewed at                                                                                          COIC
                                                   DIPC and COIC




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State              Action                 Executive    Operational Lead      Date of      Current Risk        Measure of             Evidence      Review Date
  Objective                                                                     Lead        and involved        Completion                         Success
                                                                                             individuals

4 - Ensure     Lack of clarity regarding  *     Review Trust leadership       DoN / DIPC   DoN / Execs /      28.2.2010      Unable to        New agreed            Mins of Exec mtg   31.3.2010
clear          leadership and directorate       for infection control                      DIPC                              agree structures structure agreed at
leadership     roles                                                                                                                          Exec. Meetings
and                                       *     Agree structures and roles
directorate                                     and accountability for HCAI
ownership
and
                                          *     Undertake HCAI                DoN          DDoN               1.3.2010                                              COIC minutes
accountability
                                                sustainability assessment.
for HCAI
                                                Review at COIC

                                            *   Review directorate            DoN / DIPC   DMT                1.3.2010       Review delayed                         TB reports
                                                structures and processes,                                                    by Directorate
                                                make recommendation for                                                      Management
                                                strengthening leaderships                                                    Teams
                                                including ward leaders,
                                                matrons, HoNs and GM



                                            *   Agree assurance report to DoN / DIPC       DDoN               10.3.2010                       Report in agreed      TB minutes and
                                                be provided by Directorate                                                                    format                Board papers
                                                for TMT and board
                                                including directorate level
                                                report and collated
                                                matrons walk round reports


                                            *   Review current format for     DoN/DIPC/    DDoN               25.3.2010                       Report in agreed      Board reports
                                                Trust infection control       CEO                                                             format
                                                reports




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State              Action                Executive   Operational Lead      Date of      Current Risk       Measure of              Evidence     Review Date
  Objective                                                                    Lead       and involved        Completion                        Success
                                                                                           individuals

5 - Ensure    Limited joint working         *   Cross attendance at PCT     DoN          DDoN               1.2.2010       Frequency of                            Minutes of       1.4.2010
collaborative                                   and Trust meetings                                                         meetings                                meetings eg IC
working                                                                                                                                                            Commissioning
across health                                                                                                                                                      Community DIPC
community                                                                                                                                                          minutes
                                            *   Strengthen collaboration    DoN          ICT lead           28.2.2010                       Agree key activities
                                                between infection control                                                                   ie SSI
                                                teams
                                            *   Identify areas for joint      DoN        DDoN / PCT         31.3.2010      Agreement of
                                                activity and agree action                                                  key activities
                                                plans ie training for nursing
                                                home staff




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State              Action               Executive   Operational Lead      Date of      Current Risk      Measure of             Evidence      Review Date
  Objective                                                                   Lead       and involved        Completion                       Success
                                                                                          individuals

6 - Ensure     Lack of assurance at ward *      Each ward manage to         DoN         HoN / Ward         28.2.2010      Ward sisters    Ward records of      Report to COIC -
consistency    level                            check staff knowledge of                Manager                           not able to     training             minutes
of cleanliness                                  correct procedures and                                                    provide         Records of audit -
of shared                                       implement training plan                                                   sufficient      spot check reports
equipment                                       using high impact                                                         assurances
                                            *   intervention number eight
                                                Ward manager to ensure      DoN         HoN                1.2.2010                       Matrons walk round Minutes of ward
                                                daily spot check of                                                                       report findings    manager meetings
                                                cleanliness
                                            *   Weekly spot checks by                                      Ongoing
                                                Matrons / HoNs and
                                                findings of at ward level




HCAI Data / Action Plan 5.2.10
  Local Sub                 Current State              Action                 Executive   Operational Lead      Date of     Current Risk       Measure of             Evidence      Review Date
  Objective                                                                     Lead       and involved        Completion                       Success
                                                                                            individuals

7 - Ensure          Action plan unwieldy.   *   Review HCAI action plans      DoN         DDoN               30.3.2010                     Action plan signed Mins of Exec. Board
the infection       Team lack focus             incorporating short,                                                                       off at COIC, Execs,
prevention                                      medium and long term                                                                       Board
and control                                     goals in collaboration with
team are                                        directorates, Execs, ITC                  ICT Leader                                       Clear detailed
effective in                                    and PCT                                                                                    objectives for Trust
developing                                                                                                                                 and Team
an overall
                                            *   Further develop structure     DoN                                                          Up to date ratified    COIC minutes
Trust HCA
                                                of IC team and links to                                                                    policies
action plan
                                                directorates including
                                                nursing and medical
                                                leadership
                                            *   Produce clear plan for        DoN         PD Lead ICT                                      New documents
                                                policy review and                                                                          launched
                                                documentation review eg
                                                Catheter Care Plan




HCAI Data / Action Plan 5.2.10

				
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